Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
For an asymptomatic patient discovered during workup for elevated PT/PTT to have mild prothrombin deficiency, would you suggest any preoperative prophylaxis?
In someone with normal liver function otherwise, who was found on preoperative screening to have both mildly prolonged PT and PTT, AND the only abnormality found was a factor II (2, prothrombin) level >60%, I would not administer preoperative prophylaxis. However, I find the question confusing as it...
How should one approach an incidentally found T-cell gene arrangement?
When I see an incidental T-cell clonal rearrangement without any manifestation, my first question is how was this being measured? Many PCR-based methods have a difficult time distinguishing oligoclonal versus monoclonal T-cell populations. My favored test here is looking by flow cytometry at the T-c...
What is your approach to treating genital lichen sclerosus that is not responding to super-potent topical steroids?
Biopsy is the next step if it was never done to rule out SCC or another alternative process since clobetasol typically works in these cases. Traditionally, methotrexate has been a standard treatment. However, more recently, I've started using Rinvoq off-label with great efficacy.
Which medications do you recommend for lactating mothers with kidney disease and proteinuria that persists post-delivery?
I use ACE inhibitors, including enalapril and lisinopril, in the lactating mothers with proteinuria and hypertension. Captopril is also safe, but as it is dosed multiple times per day, I avoid this. There is no data on ARBs. If they are still recovering from an AKI or there is another issue, like hy...
Aside from lifestyle measures such as calcium intake, vitamin D repletion, and weight-bearing exercises and ruling out all secondary causes, what is the preferred approach to managing osteoporosis in young women with Z score of less than -2.5 and planning to get pregnant soon?
It is very helpful to have some knowledge as to the reason for the Z score of <2.5. Young women with low BMI can have a low Z score just due to the unloading of the skeleton. Increasing body weight can often improve BMD in these women. Presumably, she has a normal menstrual cycle. If not, the instit...
What treatment modalities have you had success in treating perioral or periorbital dermatitis when they have failed Topical calcineurin inhibitor and oral antibiotics?
The first line is typically metronidazole and/or clindamycin. Topical ivermectin is also a very reasonable approach, and sulfacetamide can help as well. I typically use these before topical calcineurin inhibitors. Rarely TCIs can worsen demodex as has been reported. Which oral antibiotics? Doxycycli...
What's your treatment algorithm for notalgia paresthetica?
Topical steroids + dermeleve (otc anti-pruritic) cream ILK versus other OTC topicals (capsaicin, Sarna, pramoxine) versus compounded gabapentin, amitriptyline, lidocaine (my main go-to second line) Oral - gabapentin vs doxepin vs desipramine Recalcitrant cases I’ve added dupilumab or phototherapy w...
Are there any instances when you use vitamin B6 to prevent kidney stones in patients with recurrent calcium oxalate nephrolithiasis who do not have primary hyperoxaluria?
I occasionally try empirical vitamin B6 in patients with hyperoxaluria that does not respond to usual dietary oxalate restriction plus low fat and higher calcium. I have not done it systematically and have only a handful of cases where it may have helped. Thus, I would not recommend routinely adding...
When do you refer a patient with MODY3 to GI/Hepatology for monitoring/management of hepatic adenomas?
As you know, maturity-onset diabetes of the young type 3 (MODY 3) is a consequence of heterozygous germ-line mutations in HNF1A. In addition, hepatocellular adenoma (HCA) may be caused by somatic HNF1A mutations. There are approximately a dozen cases reported of individuals with MODY 3 and HCA (1). ...
How would you approach rheumatoid arthritis treatment for widespread large rheumatoid nodules but no active synovitis or subjective joint pain?
One needs also to consider drug-induced accelerated nodulosis. I used to see it more often in the 1990s from methotrexate, but since then, it has also been described with other drugs like TNF inhibitors and leflunomide (Patatanian & Thompson, PMID 12222551, Ahmed et al., PMID 11470988, Akiyama et al...